Bellevue Hospital

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 29000 Based on a review of the facilities emergency department log and staff interview the facility failed to list every patient who came to the emergency department (ED) seeking assistance. This affected one patient (Patient #21) of 21 patients reviewed for emergency department assistance. Findings include: An entrance conference was held on 08/14/25 with a request made to review the emergency department (ED) admission log for the past six months. A log was provided from Staff A from 02/14/25 through 08/14/25 with no documentation the Patient #21 was in the ED. A request was made for a policy related to logging patients in who come to the ED seeking treatment. Staff A and C provided a policy titled Emergency Room Triage further stating no policy is available regarding logging patients in. The policy indicated when a patient presents to the ER registration window the clerk fills out a yellow slip which includes patients name, date of birth, date of service and time of arrival and chief complaint. After triage is completed the registration clerk enters the admission into the registration system. The complaint grievance log was reviewed on 08/18/25 with an incident report dated 06/05/25 indicating a registered nurse (RN) received a call from EMS on 06/04/25 at 2:10 PM stating a patient was being transferred but the receiving facility refused admission and their dispatcher informed them to come to this hospital. Patient #21 arrived to the parking lot at 2:13 PM then was brought inside the hospital at 2:45 PM and was at the secretary area on a stretcher with EMS stating this patient needs “a psychiatric evaluation”. Notes further indicated the EMS supervisor was called and informed since no medical emergency, this patient should not be admitted here and should go back to where they came from. This patient left the property at 3:20 PM with no documentation an assessment was completed. No documentation was in the log to indicate Patient #21 arrived to the ED seeking assistance. The findings of not logging this patient in the log or staff assessing this patient was verified with Staff A on 08/20/25 at 2:30 PM.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 29000 Based on a review of the emergency department log, review of an incident report, policy review and staff interview the facility failed to complete a medical screening exam on a patient who arrived to the emergency department. This affected one patient (Patient #21) out of 21 patients reviewed for emergency services. Findings include: Staff A provided a policy titled Emergency Room Triage which revealed when a patient presents to the ER registration window the clerk fills out a yellow triage slip which includes patients name, date of birth, date of service and time of arrival then has them sign a consent to treat. Staff A provided a policy titled Patient Request/Refusal Consent to Transfer which listed each individual who comes to the Emergency Department and requests a examination or treatment, or is transferred from this hospital to another facility they shall receive an appropriate medical screening examination to determine whether an emergency medical condition exists. The complaint grievance log was reviewed on 08/18/25 with an incident report dated 06/05/25 indicating a registered nurse (RN) received a call from EMS on 06/04/25 at 2:10 PM stating a patient was being transferred but now the receiving facility refused admission and their dispatcher informed them to come to this hospital. Patient #21 arrived to the parking lot at 2:13 PM then was brought inside the hospital at 2:45 PM to the secretary area on a stretcher with EMS stating this patient needs “a psychiatric evaluation”. Notes further indicated the EMS supervisor was called and informed since no medical emergency, this patient should not be admitted here and should go back to where they came from. This patient left the property at 3:20 PM with no documentation of a medical screening completed. Interview with the ED Manager (Staff C) was completed on 08/14/25 at 11:00 AM. Staff C was asked what the process was when a squad comes or calls in and Staff C revealed they asked questions to clarify issue, give room assignment, inform staff if unstable they place in rooms 5 and 6. Staff C revealed they had a case where a squad pulled into they facility and stated the place they were transferring the patient would not accept them back. This was the only time in their 26 year career a squad came to drop off a patient for no reason. Staff C revealed they called the supervisor of the squad, and Staff C and the physician assistant came out and evaluated the patient. Staff C confirmed there was no record of the evaluation and just a incident report was filled out. Interview with the ED attending physician (Staff F) who was working during the tour on 08/14/25 was completed at 11:45 AM. Staff F revealed they do remember Patient #21 who was brought in by a squad to the ED with no emergent situation and they sent them on their way. When a patient is brought in with no emergent procedure they do what’s best for the patient. A second interview was completed on 08/19/25 at 2:10 PM after finding out this physician was working that day and Staff F revealed they were in the department and did not examine or speak with the ambulance company or the patient. Staff F thought the NP may have told them about the situation but didn’t remember any discussion as they thought the ED Manager was taking care of everything related to this. Interview with the Medical Director (Staff G) was completed on 08/14/25 at 12:15 PM. regarding the complaint process. Staff G revealed complaints come in by many ways phone calls or written, the director or manager of the ED looks at them, and Staff G gets involved if it’s physician related. When Staff G was asked about the complaint Staff C provided regarding a patient coming to the ED by squad when on route to another hospital and the ED not accepting patient, Staff G revealed they were not aware of this situation and wasn’t involved. Staff C heard some rumbling about it but was never given the complaint to review. Staff G further stated “if an EMS requests to have a patient seen they should be seen but again didn’t know about this situation”. Phone interview with Staff J on 08/21/25 at 10:38 AM revealed Staff J did not remember the scenario above and did not assess Patient #21. Staff J revealed EMS asked if we could bring him in, then the ER Manager and Staff J went out to see the patient. Staff J revealed they were never asked to assess this patient and believed the attending physician was at lunch. When Staff J was asked if they were aware EMS brought Patient #21 to the desk, Staff J revealed maybe because it was hot outside and Staff J overheard their medical person or dispatcher tell them to say he needs to have a psych evaluation. When the nurse asked if anything changed and the EMS stated no. The findings of this ED not completing a medical screening for Patient #21 when they presented to the ED desk was verified with Staff A on 08/20/25 at 2:45 PM.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 29000 Based on medical record review, policy review and staff interview, the facility failed to ensure patients reviewed their consent and authorization for transfer. This affected five patients (Patient #6, #8, #14, #15 and #16) out of 21 patients reviewed for emergency services. Findings include: Staff D provided a policy titled Patient Request/Refusal Consent to transfer (dated 2003). This policy instructed staff to fill out the Transfer Certification form for any patient transferred from this facility. This form was to be completely filled out with particular attention to all diagnosis, specific services not available at this hospital, statement that patient was discharged and a copy of this consent should be sent with the patient. The physician signs a certification that the benefits of transfer outweigh the risks to the patient. The authorization for transfer form lists under #4 the patient consents or refuses transfer and have been informed of and understand the risks, benefits associated with the transfer. 1. Review of Patient #6’s medical record revealed they came to the emergency department (ED) on 07/02/25 by ambulance with complaints of a fall yesterday and having severe low back pain today. A physician saw this patient at 9:38 AM and ordered a CT of the spine which resulted in a T 12 compression fracture. Orders were received to transport this patient to an acute care hospital for follow up with a neurosurgeon. An authorization and consent to transfer form was filled out by the physician dated 07/02/25 at 11:55 AM listing the reason for transfer along with risks and benefits. The portion of the consent under #4, consent/refusal for transfer was blank. Patient #6 was transferred out at 2:22 PM. Interview with Staff A verified on 08/19/25 at 4:45 PM confirmed there was no evidence Patient #6 signed the consent to transfer. 2. Review of Patient #8’s medical record revealed they came to the ED on 07/17/25 at 8:44 PM by ambulance with complaints of lower abdominal pain. Patient #8 stated he felt constipated, had a bowel movement yesterday, had a history of throat cancer with vomiting starting today. A nurse practitioner was into see Patient #8 at 8:52 PM with a CT scan of the abdomen ordered. This scan indicated a large amount of stool was noted throughout the colon. Review of the medical record revealed the patient was being transferred due to a upper gastro-intestinal (GI) bleed. Review of Patient #8’s authorization and consent to transfer form was in the medical record dated 07/18/25 at 7:15 AM and signed by the emergency department physician. Listed under #4 for consent/refusal to transfer as well as risks and benefits explained was left blank and not signed by the patient. Interview with Staff A verified on 08/19/25 at 4:45 PM confirmed there was no evidence Patient #8 signed the consent to transfer. 3. Review of Patient #14’s medical record revealed the patient came to the ED by ambulance on 06/04/25 at 8:52 AM. Patient #14’s notes revealed the patients grandmother called the squad due to this patient being weak and stating they took a whole bottle of Xanaflex to help them sleep. Patient #14’s physician notes revealed this patient has a history of daily alcohol usage but has not had alcohol for three days due to the expense. Orders were received to send this patient to a tertiary facility for prolonged monitoring due to the overdose of Xanaflex. An authorization and consent for transfer form was signed by the attending physician on 06/04/25 at 10:30 AM. The area under #4 consent/refusal was not signed by this patient to indicate they were informed and understands the risks and benefits for the transfer. This patient was transferred at 11:56 AM. The findings of not completing the consent for transfer was verified with Staff C on 08/20/25 at 1:30 PM. 4. Review of Patient #15’s medical record revealed Patient #15 came to the ED by ambulance accompanied by law enforcement on 06/06/25 at 3:25 AM. Patient #15’s notes revealed this patient woke up manic and poured gas on his head to try to kill themselves then ran away and the girlfriend had to call the police. A physician was into see and assess Patient #15 with orders received to transfer to a tertiary facility and this patient was transferred on 06/06/25 at 12:02 PM. A authorization and consent to transfer form was signed by the physician on 06/06/25 at 10:45 AM. The area for consent/refusal from the patient was left blank. The findings of not completing the consent for transfer was verified with Staff C on 08/20/25 at 1:30 PM. 5. Review of Patient #16’s medical record revealed the patient was a thirteen-year-old who came to this ED on 08/12/25 at 6:15 PM by ambulance after cutting her left arm 12 times with a knife. Review of Patient #16’s physician notes revealed under medical decision making: a medical clearance workup was performed and within normal lists. A drug test was completed which was negative. After lengthy discussion with this patient’s mother she requested for this patient to be admitted for psychiatric care and arrangements made for transfer. The authorization and consent for transfer form was completed by the provider with no consent or refusal by the patients guardian (mother) to indicate they understood the risks and benefits of the transfer. Patient #16 was discharged on 08/13/25 at 12:58 AM. The findings of not completing the consent for transfer was verified with Staff C on 08/20/25 at 1:30 PM.”